Plan Administrator Guide

Transcription

1 Plan Administrator Guide

2 TABLE OF CONTENTS 3 Secure Employer Website 4 Enrollment Center 5 Billing Management 6 Reports 7 Eligibility and enrollment 8 Special enrollment We provide tools to make it easy for you to manage the health plan for your company. 9 Waiving coverage 10 Cancellations 11 Children, spouse, or domestic partner 12 COBRA 13 Billing information and policies 14 Member enrollment and change application 15 Enrollment application completion tips 17 Membership administration 18 Paying your bill 19 Delinquent account and payment policies 20 Frequently asked questions

3 Secure employer website The secure employer website puts common tasks at your fingertips and helps you save time with single sign-on for many functions. Once you log in to the secure website, you can quickly and easily: View employee information and eligibility Edit member information Order ID cards Review account and billing information Determine coverage start date for new employees See reports And much more A key feature of the secure employer website is role-based access. That means what you can do on the website is determined by the role you have been assigned within the secure website. The group administrator for your company is the person who has responsibility for managing access for others. New to Premera? When a group s plan becomes effective, the group administrator will receive a letter asking them to call our Help Desk ( ) in order to receive an invitation with instructions on how to set up their account with a user ID and password. The secure employer website provides additional instructions, such as how to add users. Need technical help? Call our technical help desk at from 5 a.m. to 5 p.m. Alaska time, Monday through Friday. 3

4 Enrollment center You can reach the Enrollment Center through the secure employer website. With Premera s Enrollment Center, you can enroll employees and their eligible dependents into the system.* In addition, you can: Add a spouse or domestic partner to an existing member profile Add dependents to an existing member profile Edit subgroup information (if you have more than one subgroup) Change Class/Plan (if applicable) Terminate a member from the plan Process rehires Manage COBRA (Benefitfocus Enrollment Center only) If you are interested in access to the Enrollment Center, talk with your Premera account manager about setting up your account. Helpful Web tips When you are entering information online within the secure employer website, please keep these guidelines in mind. The only symbols that can be used in member names are the hyphen (-) and the apostrophe ( ). In addition to those two symbols, the pound sign (#) can be used in the address. Names are limited to 26 characters. This includes the member s first name, middle initial, and last name, as well as the spaces in between. This is how the name will be shown on the members ID card. Contact your membership analyst if you have additional questions. Entries using postal address standards will improve delivery of ID card and explanation of benefits. Addresses entered can only be U.S. addresses. For foreign addresses, please contact your billing representative found on the Premera website or your monthly invoice. *Additional steps may be required to enroll new members on a plan with a health savings account (HSA). 4

5 Billing management On the Billing page within the secure employer website, you can: View invoices for the past 6 months Find out where to remit payments Get summary information for each invoice (in PDF or Excel format) See the next invoice generation date Important note: Depending on your group s billing date, enrollment and eligibility changes could appear on the next billing statement. Have billing questions? If you need assistance, or have questions about the information, please contact your Premera Blue Cross Blue Shield of Alaska membership analyst. To report a technical problem, please call our technical help desk at from 5 a.m. to 5 p.m. Alaska time, Monday through Friday. 5

6 Reports The Reports page on the secure employer website gives authorized users access to reporting tools. These audit reports are designed to help you effectively manage your employee benefits. Reports are available in either PDF or Excel format. Helpful Web tips When you are entering information online within the secure employer website, please keep these guidelines in mind. The only symbols that can be used in member names are the hyphen (-) and the apostrophe ( ). In addition to those two symbols, the pound sign (#) can be used in the address. Names are limited to 26 characters. This includes the member s first name, middle initial, and last name, as well as the spaces in between. This is how the name will be shown on the members ID card. Contact your membership analyst if you have additional questions. Entries using postal address standards will improve delivery of the ID card and explanation of benefits. Addresses entered can only be U.S. addresses. For foreign addresses, please contact your billing representative found on the Premera website or your monthly invoice. 6

7 Eligibility and enrollment Use Enrollment Center to complete enrollment online. If you prefer using the paper enrollment process, each employee must complete and sign a Member Enrollment and Change Application to add, drop, or waive coverage. We require enrollment information to be submitted prior to, but no later than, 30 days from the start date. Enrollment reminders Employees or dependents who aren t enrolled when first eligible or as allowed under special enrollment below, are eligible for enrollment during the group s next open enrollment period. Open enrollment When a group chooses to renew its existing contract with Premera, members are eligible to make different benefit selections and add or drop dependents from their plan, as per the guidelines of their new contract. This period of time is known as open enrollment and is only available at the time of renewal. Any other changes to enrollment must be for one of the reasons listed below: Please let eligible employees know about the plan s waiting period and special enrollment rights before they enroll. Enrollment outside of open enrollment period ENROLLMENT REASON New employee Rehired employee COBRA Employee has entered eligible class Marriage Legal separation Divorce Death Birth Adoption Dependent change Involuntary loss of coverage Qualified medical child support orders Persons eligible for medical assistance DEFINITION Newly hired employee Rehired employee No longer eligible as a regular member but is opting to continue benefits under COBRA Change from part time to full time or temporary to permanent employment, and the like Adding dependents due to marriage Dropping dependent(s) due to legal separation Dropping dependent(s) due to legal divorce Cancellation of coverage due to member death Adding dependent(s) due to birth Adding dependent(s) due to legal adoption (legal papers are required) Adding or dropping a dependent due to changes in eligibility status, such as a qualifying event or dependent coverage status (26) Coverage with another carrier has been terminated Copy of court order may be required Newly enrolled by Department of Social and Health Services (DSHS) in the Employer-Sponsored Insurance program This change can be made online using Enrollment Center or through our employer website. Note: The employer is responsible for validating all enrollments submitted outside of open enrollment meet the above criteria. Although the plan may provide for reimbursement of expenses incurred by the domestic partner, federal tax laws restrict the plan s ability to reimburse expenses incurred by an individual who is not a tax dependent. Because the tax laws applicable to domestic partners are complicated, the member should consult with their tax advisor to determine whether their domestic partner is their tax dependent before they make any decisions under the plan. 7

8 Special enrollment The terms of your healthcare plan may allow employees and/or dependents to waive enrollment when first eligible because they have other coverage. These employees and dependents have the right to enroll later if the other coverage was lost and if certain conditions are met. Employees and dependents may enroll outside the open enrollment period for the following reasons: The employee or dependent had other healthcare coverage when the Premera Blue Cross coverage was offered. The employee declined Premera coverage for himself/herself and/or the dependent in writing, and the written notice stated that the person had other coverage. The employee or dependent lost other coverage due to legal separation, divorce, death, voluntary or involuntary termination of employment, or a voluntary or involuntary reduction in the number of hours worked. The employer terminated its contribution toward the employee or dependent s other coverage. Note: Reduction in the amount of employer contribution does not convey special enrollment rights. An employee may enroll (with or without existing dependents) at the same time a new dependent (acquired through marriage, domestic partnership, birth, or adoption) is enrolled, if the terms of your healthcare plan allowed the employee or dependent to waive enrollment when first eligible. The employee was covered under COBRA at the time this coverage was offered, and the employee s COBRA benefits have been exhausted. Note: Employees or dependents who voluntarily terminate COBRA coverage while still eligible for it do not have special enrollment rights. The employee is eligible for both state medical assistance and coverage under the Premera plan and is enrolled in the Department of Social and Health Services (DSHS) Employer- Sponsored Insurance (ESI) program. The employee may be required to provide a Notice of Eligibility from DSHS. Under the ESI program, the employee receives state subsidy for Premera coverage directly from the state. The employer is responsible for obtaining and maintaining any DSHS documentation. Note: The employer is responsible for validating all special enrollments meets the above criteria. 8

9 Waiving coverage Employees and dependents who have the opportunity to enroll for health benefits offered by your company may decline part or all of the benefits, provided that the group contract doesn t require 100 percent participation for that class of enrollee. Waiving coverage on initial enrollment An employee may enroll (with or without existing dependents) at the same time a new dependent (acquired through marriage, domestic partnership, birth, or adoption) is enrolled, if the terms of your healthcare plan allowed the employee or dependent to waive enrollment when first eligible. If an employee and/or dependent decline to enroll in the health plan, enter that information in Enrollment Center. If using the paper enrollment process, the employee must sign a waiver. Please note that for community rated groups of 1 to 50, all eligible waivers must be accompanied by a photocopy of an ID card or Explanation of Benefits (EOB) to verify current coverage. Please keep signed waivers in your files. If you need additional copies, they are available on our website, premera.com. Go to the employer section and select Forms and Supplies. 9

10 Cancellations Your employees should notify you whenever dependents are no longer eligible for coverage or are canceling coverage under your plan. To ensure that coverage is canceled, choose the appropriate method below: Enrollment Center Process enrollment cancellations via Enrollment Center. Cancellations must be completed within 60 days of receiving notice from your employee. Paper Provide written notice to Premera within 60 days from the date of notification. This notification may be submitted via directly to Cancellation criteria Below are general guidelines for coverage cancellation under most Premera plans. Check with your account representative for specific details on your plan. Employee and dependents The group s contract is canceled. The employee s employment is terminated. The employee no longer meets group s eligibility guidelines. The employee is no longer in an eligible employee class. The employee cancels coverage, provided that the group contract does not require 100 percent participation for employees. The employee is deceased. The group s subscription charges are not paid when due or within the grace period. If the plan is an association plan, when the participating employer ceases to be a member of the association. Note: Cancellations that are requested to be retroactive because of a group s clerical error will not be retroactive more than 2 months from the date a group notifies us of the error. Please note that this retroactive cancellation policy does not apply to COBRA enrollees and situations other than the group s clerical error. 10

11 Children, spouse, or domestic partner A child s, spouse s, or domestic partner s coverage will end when one or more of the following occurs: Coverage for a child, spouse, or domestic partner will end when one or more of the following occurs: The marriage or domestic partnership is terminated or the spouse divorces or legally separates from the employee (spouse or domestic partner will lose eligibility; however, enrolled children may not necessarily lose eligibility). The child reaches the allowable age limit. The employee cancels coverage, provided that the group contract does not require 100 percent participation for dependents. The child, spouse, or domestic partner dies. Court-ordered guardianship of a minor child expires or terminates. Note: The employer is responsible for validating above cancellation criteria. 11

12 COBRA COBRA is the federally mandated program that provides your employees the opportunity to continue their health coverage if they lose coverage under special circumstances. Employers may require COBRA enrollees to pay the full cost of this coverage plus an additional 2 percent. As a group administrator, you should determine whether your plan is subject to COBRA. Here are some general guidelines: Groups that had fewer than 20 employees on at least 50 percent of their working days in the previous calendar year are NOT subject to COBRA starting January 1 of the next calendar year. (For example, an employer who had 17 employees for 50 percent of its working days in 2015 is NOT subject to COBRA as of January 1, 2016.) All employees must be counted, not just those eligible for, or enrolled in, the plan. Other requirements and restrictions apply, as stated in the federal law and regulations. Individual coverage When coverage under a group plan ends, your enrollees may apply for Premera individual plan coverage. Contact your producer or account representative for more information on these plans. If your plan is subject to COBRA, please notify your account representative immediately when COBRA status changes for your employees and their dependents. 12

13 Billing information and policies UNDERSTANDING YOUR GROUP INVOICE SUMMARY The Premera group invoice summary you receive by mail provides detailed information for the current invoice period, including changes made to the account since the prior month s invoice date. CURRENT INVOICE TOTAL The current invoice total represents billing for the current month owing. PLEASE PAY THIS AMOUNT Represents the amount actually due and payable. It is calculated by adding the current invoice total PLUS any adjustments PLUS any balance forward owing from a prior billing invoice period. This is the amount that should be referenced for payment each month. Any enrollment changes processed after current month s billing statement will be reflected in subsequent month s bill. DETACH AND SUBMIT PAYMENT To ensure timely and accurate posting of your payment, please detach and submit your remittance coupon with your payment. IMPORTANT! Payments are due on the first of each month. To expedite processing when mailing your payment, please submit your payment in full along with your remittance coupon located at the bottom of your group invoice summary. Your prompt payment enables us to provide your employees with uninterrupted claims processing. 13

14 Member enrollment and change application UNDERSTANDING YOUR GROUP INVOICE SUMMARY Use the following only if you are using the paper enrollment process. The Member Enrollment and Change Application must be filled out completely in order to avoid delays in the enrollment process. Any incomplete forms will be returned to you. If you need additional copies of this form, they are available on our website: premera.com. Go to the Employer section and select Forms. PO Box Seattle, WA MEMBER ENROLLMENT AND CHANGE APPLICATION 1. GROUP INFORMATION (to be completed by the group) Group ID Group name Employee class/subgroup (as applicable) Employee Date of Hire / / Enrollment Reason If COBRA, indicate number of months eligible for coverage: 18 months 29 months 36 months 2. EMPLOYEE INFORMATION (employee to complete sections 2 through 4) Employee name (Last) (First) Contact phone ( ) Date of enrollment details Same as hire date Other date / / Contact (*Required) Plan start date / / Mailing address City State ZIP 3. ENROLLMENT INFORMATION Plan choice (as applicable) NOTE: Please indicate names as you would like it to appear on the ID card. ID card names are limited to 26 characters and spaces. Add Drop Relationship to Employee Last Name First Name Social Security No. (*Required) Date of Birth Self / / / / / / / / / / / / Gender Benefit Selection M F Medical Dental Vision Only If any dependent has a different mailing address, please attach that information. Additional information attached? No Yes If any child over the dependent age limit is applying for coverage due to disability, please complete and attach the Request for Certification of Disabled Dependent form. Please complete and attach the Other Coverage Questionnaire form if any applicant has other current health coverage, including Medicare or Premera, which will remain in effect when your Premera coverage begins. If the form is not included, then it is assumed that no other coverage is in effect. 4. EMPLOYEE SIGNATURE In applying for enrollment as indicated on this application, I declare that all of the information on this form is true and complete to the best of my knowledge. I also declare that each person I am requesting enrollment for is eligible for coverage. I have also read and understand the provisions as stated in section 5 of this document. The changes on this form supersede all previous forms submitted. Employee signature Date signed / / Please note: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits ( ) An Independent Licensee of the Blue Cross Blue Shield Association Page 2 not shown. 14

15 Enrollment application completion tips Use Enrollment Center to complete enrollment online. The following is applicable only if you are using the paper enrollment process. Section 1: Group information To be completed by the group administrator as follows: Group ID. Your group number. Group name. Enter your group name. Mark the application as new or change. Select an enrollment reason Note: The employer is responsible for validating that all enrollments submitted outside of open enrollment meet acceptable criteria. New/change. Mark the new box if you are adding a new subscriber to your plan. Mark the change box if you are making changes to an existing subscriber. Reason. The enrollment reason is required. Please refer to Enrollment outside of open enrollment period for a list of acceptable qualifying events. Date of event. Date of enrollment reason (enter full date). (Example: John Smith got married on 2/14/15 and would like to add his spouse. Enrollment reason = Marriage, Date of Event = 2/14/15.) Employee class. SubGroup ID or class name. Employee job title. Enter employee job title. Date of hire. Date employee was originally hired by your company. In the case of a rehire, enter the rehire date. Date employee entered eligible class. The date the employee qualified for health benefits Generally, this date is the same as the hire date for full-time employees. In the case of part-time employees, enter the date they became eligible for health benefits as per your contractual agreement. (Example: Employee A hired 1/1/14 as part time; became full time effective 2/1/15 and is now eligible for health benefits. In this example, you would use 2/1/15.) Same as hire date. Check this field if date entered eligible class is the same as the hire date. Starting date. Enter the date the employee will begin receiving benefits. Refer to your contract to determine what the effective date would be following satisfaction of a probationary waiting period, if one applies. COBRA. Complete this section only if applicable. Section 2: Employee information To be completed by employee. All information must be legible and completed. Member names must be written exactly as they should appear on the ID card (limited to 26 characters for full name, including spaces). The member must shorten the name if their name is more than 26 characters. Employee home address must be completed in full. Mailing address. Only complete if correspondence should be mailed to different address than home address. 15

16 Section 3: Enrollment information To be completed by employee. Plan choice. Write in plan selected. Add/drop/waive. Complete appropriate box for each member. Relationship to employee. Describe dependents relationship to employee. Last name, first name, MI. Clearly write member s name exactly as it should appear on the ID card (limited to 26 characters including spaces for full name). Social Security Number. Write in each member s Social Security number. Date of birth. Write in each member s full date of birth (mm/dd/yy). Gender. Each member must have a gender selected. Premera will not make assumptions based on name. Benefit selection. Indicate benefit selection for each member (dependent member benefit selections left blank will default to employee benefit selections). Different dependent mailing address. Provide full address if correspondence should be mailed to a different address. Specific member names should be listed, otherwise correspondence will default to employee s address. Disabled dependent information. If dependent coverage is due to disability, please complete the Request for Certification of Disabled Dependent form located on premera.com under Forms. Newborn coverage and rate impact The Erin Act provides that when a mother s health plan coverage includes maternity benefits, her newborn child will receive three weeks (21 days) of coverage under the plan, regardless of whether the child is ultimately enrolled in the plan. If a newborn is added to the policy, the premium will appear on the billing the first of the month following the month the newborn is added. Contact your membership analyst, whose name and telephone number is included on your billing statement, if you have any questions. If the newborn addition does not change a dependent coverage level, then rates will not be affected. Section 4: Employee signature Employee must read, sign, and date this enrollment application, which verifies data is accurate. Submission of enrollment applications Note: If enrollment is completed via the Enrollment Center, do not submit hard copy enrollment form to Premera. Fax. Please send to Note: Do not submit hard copy enrollment form to Premera for faxed documents. . If you have scanning capabilities, you may the application directly to Membership & Billing at premeramembership@premera.com. Note: Do not submit hard copy enrollment form to Premera if document is ed. Mail. Enrollment forms can be mailed to: Premera Blue Cross Blue Shield of Alaska PO Box 327 MS 737 Spokane, WA

17 Membership administration The following data must be provided for member enrollment, termination, and demographic changes: Type of transaction member enrollment or termination, plan change, or a demographic change (such as a change of name or address) Your group identification number Your employee s subscriber identification number, or, if unavailable, the employee s social security number (the member s social security number is required to enroll new members) The group s unique employee identification number, if any The affected member s first name, last name, and middle initial The affected member s date of birth, gender, and, for dependents, relationship to the subscriber The date the coverage is to start or end, as applicable For COBRA members, the date the maximum COBRA period is to end The start and end dates of the member s prior coverage. We will use this information for pre-existing waiting period crediting. This information must be provided for waiting period credit to be given. The affected subscriber s hire date Your subgroup identification number Your medical, dental, pharmacy, and vision plan identification codes, as applicable The member s complete address (street and number, city, state, and ZIP code). If more than one address is provided, the home and mailing addresses must each be identified. 17

18 Paying your bill Automated payments For your convenience, we accept payments via the secure employer website, by phone, Automated Clearing House (ACH), bill pay, and wire transfer. For more information on setting up an ACH payment process, contact the membership and billing team at Pay by phone Call Pay by mail Pay your bill by mailing the payment along with your payment remittance coupon to: Premera Blue Cross Blue Shield of Alaska PO Box Seattle, WA A self-addressed envelope is enclosed with your monthly group invoice. Indicate your group number on your check to expedite the processing of your payment. Enrollment changes or correspondence attached to payments may result in processing delays. To expedite processing, only send payments to PO Box All other information should be ed to premeramembership@premera.com or faxed to

19 Delinquent account and payment policies The Premera Blue Cross Blue Shild of Alaska group contract defaults to a subscription charge due date of the first of each month with a 10-day grace period. If payment is not received by the end of the grace period, the group contract will be automatically terminated, retroactive to the subscription charge due date. Contract excerpt PAYMENT OF SUBSCRIPTION CHARGES AND GRACE PERIOD The first payment of subscription charges is due in advance of the contract s start date. After that, the group will pay the monthly subscription charges by the subscription charge due date, as set forth on the face page of the contract, of each following month. After the first payment, there is a grace period of 10 days from each due date in which to pay subsequent subscription charges. If payment is not received by us by the end of the grace period, the contract will automatically terminate on the subscription charge due date. Our acceptance of late or inadequate subscription charges shall not be construed as a waiver of our rights. No benefits are payable for expenses incurred on any date for which subscription charges are not paid. The group is liable for all subscription charges covering any period of time that this contract remains in force. If your payment is not received by the first of each month, you will receive a cancellation warning notice. If you lost your billing statement or did not receive your bill, you may download a copy at premera.com. Billing statements may be accessed online for up to 6 months. If you did not receive your billing statement in a timely manner, contact your membership analyst. Reinstatement of a contract without a lapse in coverage is available only to accounts that have no prior reinstatements. Premera strictly enforces its one-time per contract year. Note: During your renewal month, your regularly scheduled bill may be suspended to ensure an accurate bill is mailed to you. If you do not see your bill on schedule, contact your membership analyst. 19

20 Frequently asked questions Can I make changes online? Yes, you can add or terminate members if you use Enrollment Center. To order ID cards or view your billing statements, go to premera.com. If you need to register, please call our Web support help desk, at Once I submit my enrollment do I need to submit a hard copy? No, if you submit enrollment via fax, Enrollment Center, or , you do not need to follow up with a hard copy of the enrollment application. Our fax number is When should I submit enrollment changes? Submitting enrollment changes as they occur will ensure your billing accurately reflects your most current eligibility. When will changes show up on my statement? Additions or terminations submitted after your billing cycle will be reflected on your next month s billing statement. To expedite the reconciliation of your group s account as well as ensure prompt claims payment, please pay as billed. Why haven t I received my bill yet? During your renewal month, your group bill may be suspended to ensure an accurate bill is mailed to you. If you do not see your bill on schedule, please contact your membership analyst. How can I ensure my payment is accurately processed? Returning your payment stub, found on the bottom of your monthly invoice, and noting your group number on your check, will assist in ensuring your payment is properly credited. Can my membership analyst answer my questions about benefits and claims? No, your membership analyst cannot answer questions pertaining to benefits or claims processing. Please call Premera Blue Cross Blue Shield of Alaska customer service at for these types of questions. Where can I find contact info for my membership analyst? Your membership analyst s name and direct telephone number are listed on page one of your monthly invoice. Can I make my group s premium payment online? Yes, log in at premera.com, go to Tools, then Billing and accept the new Terms and Conditions. Be sure to check that your auto-pay settings and profile information are correct and up to date. For more information, visit the Billing page or call If I make a payment online or by phone, how long does it take for my payment to process? Payments set up after 2 p.m. will process the next business day. Payments set up prior to 2 p.m., will post the same day. This does not apply to payments sent by mail. Will Premera accept credit card payments over the phone or through the website? No, Premera will continue to support checking account payments only. Is there a charge for paying over the phone or through the website? No, we want to make this process as easy for you as possible. Therefore, when making payments via the website or over the phone, there is no additional charge. 20

21 MEMBERSHIP AND BILLING For questions related to enrollment and billing or payments, please contact our membership and billing team at BUSINESS OFFICES th St. SW Mountlake Terrace, WA EXPRESS SCRIPTS PHARMACY LOCATOR Call this toll-free number to find a network pharmacy near you. CUSTOMER SERVICE For questions related to benefits or claims processing, please contact our customer service team at CLAIMS SUBMISSION Premera Blue Cross PO Box Seattle, WA HOUR NURSELINE Nurses are available 24 hours a day, 7 days a week. The number can be found on the back of the members Premera Blue Cross member ID card or directly through our mobile app. WEB SUPPORT HELP DESK support@premera.com ( )